Diagnosing incontinence

Both urinary incontinence (UI) and faecal incontinence (FI) can be a symptom or sign of another health condition.

For this reason, it’s important to identify the cause. Anybody with a degree of incontinence that affects his or her lifestyle should see a health professional.

All but the most minor degrees of incontinence tend to be extremely inconvenient and can impact negatively on your social, sexual, recreational and working life.

The upside is that the majority of people with incontinence can either be cured, or the condition can be markedly improved.

Diagnosing urinary incontinence 

The diagnosis of UI is based on a medical history, a physical examination, and some confirmatory tests. Your health professional has to identify the type and severity of the incontinence, as well as the possible underlying cause(s).

A bladder diary is a valuable tool that will help your doctor to get a clear picture of the extent of your symptoms. Your doctor will also want to get a urine sample, so it’s best not to empty your bladder immediately before the visit.

Set aside a day or two before your doctor’s appointment to create the diary. Take note of how many times you went to the toilet, how many times you experienced the urge to run to the toilet, how often you accidentally leaked urine, and what you were doing when this happened. Also quantify your fluid and food intake, using the table below.

A careful history can help your doctor to identify the type of incontinence you have. The amount of protection you need (e.g. pads) will give your doctor some indication of the severity of the problem.

Your doctor will take note of your voiding pattern and ask direct questions with regards to other urinary tract symptoms, e.g. whether you experience painful or difficult urination. Any concurrent or previous medical, surgical or obstetric history will be noted.

Your doctor will examine your bladder to see if it’s full or empty, and whether it’s tender or not. A basic neurological examination will also be performed to rule out any neurological causes for the incontinence. Your underwear and pads may be examined for evidence of wetness and your genital skin area will be inspected for evidence of urine-induced dermatitis (red, swollen, sore skin).

If you’re a woman, your urethra and vagina will be examined next. This is usually done with a speculum in place. Your doctor will specifically look for atrophy (wasting away) of the tissues and for evidence of leaking with coughing (a sign of stress incontinence). An assessment will be made of the integrity of your bladder and the urethral support. 

A urine sample will be tested for evidence of infection and blood.

Special tests

The special tests that are performed will depend on the findings of the history and physical examination, and the suspected cause of the incontinence. The tests may include:

• Urine test: Your doctor will first do a urine dipstick test to look for any signs of infection. If there’s an indication of a urinary tract infection, your doctor will send your urine away to the lab to confirm and identify the organism that’s causing it. 
• Pad test: Your doctor may provide you with weighted, absorbent sanitary pads that you’ll have to wear until urine leakage occurs. The soiled pad will then be weighed. This test is conducted to determine the frequency and severity of the incontinence, but isn’t routinely done. 
• Ultrasound scan: This scan uses very high-frequency sound waves to obtain images of the kidneys and bladder. In the context of UI, it’s used to check for evidence of obstruction and incomplete emptying. Usually, only a bladder scan is done to check the amount of urine that remains in the bladder after passing urine. This is particularly significant in individuals who find it difficult to pass urine, or who have a history of repeated urine infection.

Doctors sometimes simply insert a catheter soon after urination to measure the urine volume that’s left. But this method is often uncomfortable, and there’s a small risk of infection. The bladder scan is generally preferable. 

• Intravenous pyelogram (IVP): During this test, a contrast medium is injected into a vein and excreted by the kidneys. Serial X-rays are taken while the contrast passes through the urinary tract, demonstrating both the function and the anatomy of the system.
  
• Micturating cystourethrogram (MCUG): A contrast medium is inserted into the bladder. By means of a catheter, X-rays are taken when the bladder is full and while you pass urine. The position and integrity of the bladder and urethra are made visible.
  
• Urodynamic study: This is a functional test of bladder muscle and bladder outlet function. Pressure probes are inserted into your bladder and rectum. During the initial filling phase, the bladder’s compliance, capacity and response to filling are measured. After capacity is reached, you’ll be asked to pass urine. The pressure generated in your bladder, as well as your bladder-outlet resistance, are measured.
  
• Cystoscopy: This is the visual inspection of the inside of the urethra and bladder with a special instrument.

Diagnosing faecal incontinence

Identifying the exact causes of FI usually starts with a doctor’s consultation and assessment, which includes a thorough medical history. 

Your doctor is likely to ask about your symptoms, diet, medication, bowel habits, and any other medical problems or factors that could affect bowel function. This information is important because FI can be linked to many other health conditions.

Your doctor may decide to refer you to a specialist for a physical examination and further tests. Once the test results and diagnosis are completed, you’ll be informed about the most appropriate treatment. Even though you might find it awkward to discuss bowel problems, remember that many others are in the same situation.

It helps to know what type of questions the doctor may ask. Here’s what to expect:

• When did your FI start and how often does it occur?
• How much stool leakage occurs? Does it just soil your underwear? Is there only a small amount of solid or liquid stool that leaks out or do you experience complete loss of bowel control?
• When you experience FI, do you have a strong urge to have a bowel movement or does it happen without warning?
• Do you have control over passing wind?
• How does the incontinence affect your daily life?
• Do you find the incontinence worsens after eating? Are there certain foods that seem to make it worse?

Consider keeping a stool diary for a few weeks, recording details of your daily bowel movements. This will make answering your doctor’s questions easier.

Read more:
Treating incontinence

Reviewed by Dr Dakalo Muavha, Specialist in Obstetrics & Gynaecology, MBChB DipObs FCOG Mmed, University of Cape Town and Groote Schuur Hospital. May 2018.